You've completed the initial step of the accident analysis by gathering information and using it to break the accident down into an accurate sequence of events. You have a good mental picture of what happened. Now it's time to continue the analysis process by completing each of the following three phases of analysis to determine what caused those events. This module will introduce us to three phases of analysis:
We'll cover each of these three phases of analysis in more detail in the next few sections.
It's important to understand all injuries to workers are caused by one thing: the harmful transfer of energy. Let's take a look at some examples that illustrate this important principle.
In the next section, we'll take a closer look at each of the types of energy that might cause injury.
The important point to remember here is the "direct cause" of the injury is not the same as the "surface cause" of the accident event.
In the last module, you learned that each event in our sequence will include an actor and an action that may have contributed to the accident. Once we have identified the actors and actions in the sequence of steps, our next job is to analyze each event to determine the surface causes for the accident.
The surface causes of accidents are those hazardous conditions and unsafe or inappropriate behaviors within the sequence of events that have directly caused or contributed in some way to the accident. It's important to understand that surface causes describe unique conditions or individual behaviors.
A hazardous condition is characterized by the following:
Unsafe or Inappropriate Behaviors are characterized by:
It's important to know most hazardous conditions in the workplace are the result of the unsafe or inappropriate behaviors that produced them.
The root causes for accidents are the underlying SMS weaknesses that consist of thousands of variables, any number of which can somehow contribute to the surface causes of accidents. This level of investigation is also called "common cause" analysis (in quality terms) because you're identifying a system component that may contribute to common conditions and behaviors that exist or occur throughout the company. These weaknesses can take two forms.
Ultimately, for the SMS to be effective, both the design and implementation must be effective.
When conducting an accident investigation, a basic assumption should be that somehow the SMS has failed. The investigation will either verify this assumption, or prove it wrong. Most of the time, it will be verified. Why is that? Most accidents in the workplace result from unsafe work behaviors.
These statistics imply that, because SMS weaknesses contribute in some way to workplace hazardous conditions and unsafe behaviors, those weaknesses are ultimately responsible for almost all workplace accidents. So, the basic assumption should be that, ultimately, most accidents are the result of SMS weaknesses, not unsafe behaviors or hazardous conditions.
To effectively fulfill your responsibilities as an accident investigator, you must not close the investigation until these root causes and solutions have been identified.
In this step we propose recommendations that include effective immediate corrective actions and system improvements that, when applied effectively, can transform the investigation into valuable "proactive" process that helps to prevent future injuries. It's important to divide your recommendations into the categories below:
Some employers may assign the responsibility for making recommendations to safety directors or other managers. However, you, as the accident investigator, may be required to take on this very important responsibility. Consequently, it's a good idea to know where to start, and how to write strong recommendations.
One tip up front: If you find the responsibility is yours, be sure to get the help of experts if you are unsure how to proceed. OSHA consultants, other safety professionals or your workers' compensation insurer can be a great source for help.
Safety professionals recognize several primary control strategies to eliminate or reduce health hazards and employee exposure to those hazards. These basic control strategies are further organized into a "Hierarchy of Controls." ANSI/ASSP Z10-2012, Occupational Health and Safety Management Systems, encourages employers to use the following hierarchy of hazard controls when making recommendations for corrective actions and system improvements:
The first three strategies attempt to control hazards and the bottom three strategies try to change exposure to hazards. Controlling hazards is always preferred to controlling behavior, and that's why these strategies are at the top of the hierarchy.
These strategies attempt to control employee behaviors to eliminate or reduce exposure to existing health hazards when hazard controls are not adequate. Naturally it's more difficult to control behaviors than hazards because we're dealing with human behavior.
You must "sell" management on the benefits of approving your recommendations. To most effectively do that, emphasize the bottom line - how they will benefit financially. Educate management on the direct and indirect accident cost savings realized if your recommendations are approved.
Direct and Indirect Cost Savings: Indirect costs can be over four times direct costs when an accident occurs. To help management understand the bottom-line financial benefits from approving recommendations, emphasize the financial benefits. The most common way of doing this is to estimate the direct and indirect cost savings.
OSHA's Safety Pays software is an excellent tool that estimates direct and indirect accident costs. It also calculates the business volume required to cover those costs. The data is based on 52,000 lost-time claims submitted to a major workers compensation insurance carrier.
Another good recommendation strategy is to provide the decision-maker with alternative corrective actions. This will increase the probability that the decision-maker will choose one of the alternatives. Your options might follow the logic below:
Now that you have accurately assessed and analyzed the facts related to the accident and developed effective corrective actions and system improvements, you must report your findings to those who have the authority to take action.
One of the most common reasons an accident investigation might fail to fulfill its intended purpose of helping to eliminate similar accidents, is that the report form is poorly designed. They actually make it difficult to get beyond identification of only surface causes: root causes are often ignored. Consequently, system improvements are not recommended.
Let's look at one format that is designed to emphasize root cause analysis. Take a look at a sample accident report. This is a report format similar to that used by OSHA accident investigators in conducting workplace accident investigations, but it goes further. This form includes the identification of safety management system weaknesses and recommended improvements. You may want to print this form while we discuss the various sections.
This section contains background information that answers questions about who the victim is, and the time, date, location of the accident, as well as other necessary details. Make sure you obtain all of this information for possible later reference.
This section presents a descriptive narrative of the events leading up to, including and immediately after the accident. It's important that the narrative paint a vivid "word picture" so that someone unfamiliar with the accident can clearly see what happened.
Click on the button to see a sample description of an accident.
The findings section describes the hazardous conditions, unsafe behaviors and the system weaknesses your analysis has uncovered. Each description of a surface or root cause will also include justification for the finding. The justification will explain how you came to your conclusion.
Unfortunately, the most common failure found in accident reports is they address only surface causes. Consequently, similar accidents recur. These report forms may have a format that "forces" the investigator to list only surface causes for accidents. The form does not "report" the system weaknesses associated with each surface cause. Consequently, the investigator believes the job is done without ferreting out the system weaknesses representing the root causes.
Other forms may actually require the investigator to indicate the status of employee negligence. Now, how can the accident investigator assure an interviewee or any other employee that the purpose of the analysis process is to "fix the system -- not the blame," when the report form shouts "negligent"?
To complete this section, just state the facts: The hazardous conditions, unsafe behaviors, practices, and inadequate or missing programs, policies, plans, processes and procedures that produced them. Be sure to write complete descriptive sentences. Not short cryptic phrases.
Take a look at this sample Section III: Findings and Justifications.
If root causes are not addressed properly in Section III of the report, it is doubtful recommendations in this section will include improving system inadequacies. Effective recommendations will describe ways to eliminate or reduce both surface and root causes. They will also detail estimated costs involved with implementing corrective actions. Let's take a closer look at effective recommendation writing. Review this sample Section IV. Recommendations.
This section contains a brief review of the causes of the accident and recommendations for corrective actions. In your review, it's important to include language that contrasts the costs of the accident with the benefits derived from investing in corrective actions. Including bottom-line information will ensure that your recommendation will be understood and appreciated by management. Remember, it's never appropriate for the accident investigator to recommend disciplinary action. Disciplinary action should be considered only by managers and only after very careful consideration of all of the facts. By the way, if system weaknesses that contributed to the accident are identified, discipline is likely unnecessary.
Open document: The accident investigation report should be considered an open document until all recommendations have been addressed.
Well, that winds up the final module in this course. Answer the final question and check your answers. Then, head over to the final 10-question exam.
Click on the "Check Quiz Answers" button to grade your quiz and see your score. You will receive a message if you forgot to answer one of the questions. After clicking the button, the questions you missed will be listed below. You can correct any missed questions and check your answers again.